Basic Information
| Provider Information | |||||||||
| NPI: | 1093762098 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUCAS | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 33 LEWIS RD | ||||||||
| Address2: | 2ND FL | ||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077298156 | ||||||||
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| Practice Location | |||||||||
| Address1: | 179 RIVER ST | ||||||||
| Address2: | |||||||||
| City: | ONEONTA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 138202239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6074333484 | ||||||||
| FaxNumber: | 6074325790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 05/03/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0207X | 188726 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology | 208000000X | 188726 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0012617180002 | 05 | PA | MEDICAID |